Dentists! Defend yourself against medical malpractice suits with proper notes and documentation

No dentist wants to be sued. One of the best ways to either avoid a lawsuit or defend yourself and your practice in a lawsuit is for the dentist and staff to maintain consistent documentation of patient care.

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No dentist wants to be sued. One of the best ways to either avoid a lawsuit or defend yourself and your practice in a lawsuit is for the dentist and staff to maintain consistent documentation of patient care.

On one hand, the oral-systemic health link has been great for our field. It allows us see how our work restores not just a patient’s smile, but his or her total health. The link encourages us to treat our practices as dental wellness centers and to work closely with physicians to ensure that patients receive the best possible care. It allows us to offer new treatment options to patients and help them afford necessary treatments because we can treat medical conditions and bill medical insurance.

However, all these great advances in dental treatment also bring new risks. When working with physicians and medical insurance companies, it’s essential to document everything—the diagnoses, treatments, conversations with a patient, and even efforts to follow up with a patient’s primary care provider (PCP). If you don’t document, you may find yourself thrown under the bus when a patient sues a medical doctor for malpractice.

Here’s an example. A woman’s PCP told her to stop taking her Coumadin in preparation for periodontal surgery. She stayed off the medicine for eight days post-surgery, and on the ninth day suffered a stroke. She is suing her PCP because she says he neglected to tell her when to restart her Coumadin after surgery, and thus caused the stroke.

The PCP’s lawyers are trying to take advantage of a rule that allows for “non-party at fault.” This is when the defendant in a malpractice suit says that the injury is actually the fault of someone else who was not named as a defendant. The PCP and his lawyers are trying to shift blame to the periodontist. They argue that if the periodontist had told the patient to call her PCP, she would have called the PCP’s office and resumed her Coumadin in a timely manner. In their mind the negligent party is the periodontist, not the PCP.

Here’s the problem for the periodontist. He may or may not have told his patient to contact her PCP. However, there’s no note in her chart saying that he told her to do that, so as far as the court is concerned, he said nothing. He may well be negligent in their eyes, even if he warned her, because he has no proof that he told her to follow up with her PCP. He is in danger of being sued because he did not carefully document every aspect of his interactions with this patient.

People call me the “Judge Judy of documentation.” I urge my clients to document carefully and exhaustively. Documentation saves a lot of grief. Include proper documentation in your practice and make it part of your routine. Your notes and documentation are the only things standing between you and a lawsuit. Are you documenting enough?

Here are key areas where practices fall short, and what steps they need to take:

Ask PCPs for referrals to establish medical necessity
Collect exhaustive documentation of diagnostic tools and procedures used
Get signed waivers for procedures such as x-rays
Attain signed “Consent of Medical Provider” from PCP before treating patients who take certain medications or have certain medical conditions
Keep post-treatment instructions in the chart or hand them to patients. Having patients sign off on the instructions is even better.
Send follow-up reports to PCPs stating what the procedure was, what the results were, and any need for further PCP involvement
Schedule follow-ups with PCP, or have patients waive a scheduled follow-up before they leave the office after a procedure

The growing awareness of the oral-systemic health link has transformed dental professionals into oral physicians. It’s time for us to start paying close attention to documentation so that our practices can thrive and we can avoid lawsuits.


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Christine Taxin is the founder and president of Links2Success. She provides consulting services to the dental community on cross coding dental-medical billing. Get the help you need to optimize dental billing. Contact Links2Success today!

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